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Author : Great Britain. National Audit Office
Publisher : Unknown
Page : 88 pages
File Size : 43,6 Mb
Release : 2005
Category : Drugs
ISBN : OCLC:895059136
Author : Institute of Medicine,Board on Health Care Services,Committee on the Work Environment for Nurses and Patient Safety
Publisher : National Academies Press
Page : 485 pages
File Size : 47,5 Mb
Release : 2004-03-27
Category : Medical
ISBN : 9780309187367
Building on the revolutionary Institute of Medicine reports To Err is Human and Crossing the Quality Chasm, Keeping Patients Safe lays out guidelines for improving patient safety by changing nurses' working conditions and demands. Licensed nurses and unlicensed nursing assistants are critical participants in our national effort to protect patients from health care errors. The nature of the activities nurses typically perform â€" monitoring patients, educating home caretakers, performing treatments, and rescuing patients who are in crisis â€" provides an indispensable resource in detecting and remedying error-producing defects in the U.S. health care system. During the past two decades, substantial changes have been made in the organization and delivery of health care â€" and consequently in the job description and work environment of nurses. As patients are increasingly cared for as outpatients, nurses in hospitals and nursing homes deal with greater severity of illness. Problems in management practices, employee deployment, work and workspace design, and the basic safety culture of health care organizations place patients at further risk. This newest edition in the groundbreaking Institute of Medicine Quality Chasm series discusses the key aspects of the work environment for nurses and reviews the potential improvements in working conditions that are likely to have an impact on patient safety.
Author : Ronda Hughes
Publisher : Department of Health and Human Services
Page : 592 pages
File Size : 54,6 Mb
Release : 2008
Category : Medical
ISBN : IOWA:31858055672798
"Nurses play a vital role in improving the safety and quality of patient car -- not only in the hospital or ambulatory treatment facility, but also of community-based care and the care performed by family members. Nurses need know what proven techniques and interventions they can use to enhance patient outcomes. To address this need, the Agency for Healthcare Research and Quality (AHRQ), with additional funding from the Robert Wood Johnson Foundation, has prepared this comprehensive, 1,400-page, handbook for nurses on patient safety and quality -- Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043)." - online AHRQ blurb, http://www.ahrq.gov/qual/nurseshdbk/
Author : Great Britain: National Audit Office
Publisher : The Stationery Office
Page : 100 pages
File Size : 45,8 Mb
Release : 2005-11-03
Category : Medical
ISBN : 9780102933444
The Department of Health estimates that one in ten patients admitted to NHS hospitals will be unintentionally harmed (a rate similar to other developed countries), due to incidents such as an injury from a fall, medication errors, equipment related incidents, record documentation errors and hospital acquired infections. About half of such incidents could have been avoided, if lessons from previous incidents had been learned. This NAO report examines the progress being made in the NHS to improve the patient safety culture, to encourage incident reporting and to learn lessons for the future. The report finds that most trusts have developed a predominantly open and fair reporting culture at the local level, driven largely by the Department of Health's clinical governance initiative and more effective risk management systems. However, a 'blame culture' still exists in some trusts, and there have been delays in establishing an effective national reporting system. There is scope for improving strategies for sharing good practice and for monitoring that lessons are learned.
Author : Great Britain: Parliament: House of Commons: Committee of Public Accounts,Edward Leigh
Publisher : The Stationery Office
Page : 52 pages
File Size : 48,8 Mb
Release : 2006-07-06
Category : Medical
ISBN : 0215029623
Everyday the NHS successfully treats over 1 million people. However there are risks and treatments can go wrong. A report by the Chief Medical Officer in 2000, ('An organisation with a memory', ISBN 0113224419) estimated that one in ten patients admitted to hospital were unintentionally harmed and that a blame culture and lack of a national system for sharing experience were key barriers to reducing the number of patient safety incidents. In Government's response included plans, timetables and targets to promote patient safety and the establishment of the National Patient Safety Agency. This report finds that insufficient progress has been made. In particular there is a question mark over the National Patient Safety Agency because of cost over-runs and delays in its National Reporting and Learning System and the limited feedback it has so far provided to trusts.
Author : Institute of Medicine,Committee on Quality of Health Care in America
Publisher : National Academies Press
Page : 312 pages
File Size : 40,7 Mb
Release : 2000-03-01
Category : Medical
ISBN : 9780309068376
Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€"three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€"but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€"with state and local implicationsâ€"for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€"which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€"it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€"as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine
Author : Peter Pronovost,Eric Vohr
Publisher : Penguin
Page : 237 pages
File Size : 40,9 Mb
Release : 2010-02-18
Category : Health & Fitness
ISBN : 9781101185278
The inspiring story of how a leading innovator in patient safety found a simple way to save countless lives. First, do no harm-doctors, nurses and clinicians swear by this code of conduct. Yet in hospitals and doctors' offices across the country, errors are made every single day - avoidable, simple mistakes that often cost lives. Inspired by two medical mistakes that not only ended in unnecessary deaths but hit close to home, Dr. Peter Pronovost made it his personal mission to improve patient safety and make preventable deaths a thing of the past, one hospital at a time. Dr. Pronovost began with simple improvements to a common procedure in the ER and ICU units at Johns Hopkins Hospital. Creating an easy five-step checklist based on the most up-to-date research for his fellow doctors and nurses to follow, he hoped that streamlining the procedure itself could slow the rate of infections patients often died from. But what Dr. Pronovost discovered was that doctors and nurses needed more than a checklist: the day-to-day environment needed to be more patient-driven and staff needed to see scientific results in order to know their efforts were a success. After those changes took effect, the units Dr. Pronovost worked with decreased their rate of infection by 70%. Today, all fifty states are implementing Dr. Pronovost's programs, which have the potential to save more lives than any other medical innovation in the past twenty-five years. But his ideas are just the beginning of the changes being made by doctors and nurses across the country making huge leaps to improve patient care. In Safe Patients, Smart Hospitals, Dr. Pronovost shares his own experience, anecdotal stories from his colleagues at Johns Hopkins and other hospitals that have made his approach their own, alongside comprehensive research-showing readers how small changes make a huge difference in patient care. Inspiring and thought provoking, this compelling book shows how one person with a cause really can make a huge difference in our lives.
Author : Robert Wears
Publisher : Oxford University Press, USA
Page : 305 pages
File Size : 46,6 Mb
Release : 2019-12
Category : Medical
ISBN : 9780190271268
The term "patient safety" rose to popularity in the late nineties, as the medical community -- in particular, physicians working in nonmedical and administrative capacities -- sought to raise awareness of the tens of thousands of deaths in the US attributed to medical errors each year. But what was causing these medical errors? And what made these accidents to rise to epidemic levels, seemingly overnight? Still Not Safe is the story of the rise of the patient-safety movement -- and how an "epidemic" of medical errors was derived from a reality that didn't support such a characterization. Physician Robert Wears and organizational theorist Kathleen Sutcliffe trace the origins of patient safety to the emergence of market trends that challenged the place of doctors in the larger medical ecosystem: the rise in medical litigation and physicians' aversion to risk; institutional changes in the organization and control of healthcare; and a bureaucratic movement to "rationalize" medical practice -- to make a hospital run like a factory. If these social factors challenged the place of practitioners, then the patient-safety movement provided a means for readjustment. In spite of relatively constant rates of medical errors in the preceding decades, the "epidemic" was announced in 1999 with the publication of the Institute of Medicine report To Err Is Human; the reforms that followed came to be dominated by the very professions it set out to reform. Weaving together narratives from medicine, psychology, philosophy, and human performance, Still Not Safe offers a counterpoint to the presiding, doctor-centric narrative of contemporary American medicine. It is certain to raise difficult, important questions around the state of our healthcare system -- and provide an opening note for other challenging conversations.
Author : Institute of Medicine,Board on Health Care Services,Committee on the Work Environment for Nurses and Patient Safety
Publisher : National Academies Press
Page : 485 pages
File Size : 52,6 Mb
Release : 2004-02-27
Category : Medical
ISBN : 9780309133272
Building on the revolutionary Institute of Medicine reports To Err is Human and Crossing the Quality Chasm, Keeping Patients Safe lays out guidelines for improving patient safety by changing nurses' working conditions and demands. Licensed nurses and unlicensed nursing assistants are critical participants in our national effort to protect patients from health care errors. The nature of the activities nurses typically perform â€" monitoring patients, educating home caretakers, performing treatments, and rescuing patients who are in crisis â€" provides an indispensable resource in detecting and remedying error-producing defects in the U.S. health care system. During the past two decades, substantial changes have been made in the organization and delivery of health care â€" and consequently in the job description and work environment of nurses. As patients are increasingly cared for as outpatients, nurses in hospitals and nursing homes deal with greater severity of illness. Problems in management practices, employee deployment, work and workspace design, and the basic safety culture of health care organizations place patients at further risk. This newest edition in the groundbreaking Institute of Medicine Quality Chasm series discusses the key aspects of the work environment for nurses and reviews the potential improvements in working conditions that are likely to have an impact on patient safety.
Author : Lucian L. Leape
Publisher : Springer Nature
Page : 450 pages
File Size : 49,5 Mb
Release : 2021-05-28
Category : Medical
ISBN : 9783030711238
This unique and engaging open access title provides a compelling and ground-breaking account of the patient safety movement in the United States, told from the perspective of one of its most prominent leaders, and arguably the movement’s founder, Lucian L. Leape, MD. Covering the growth of the field from the late 1980s to 2015, Dr. Leape details the developments, actors, organizations, research, and policy-making activities that marked the evolution and major advances of patient safety in this time span. In addition, and perhaps most importantly, this book not only comprehensively details how and why human and systems errors too often occur in the process of providing health care, it also promotes an in-depth understanding of the principles and practices of patient safety, including how they were influenced by today’s modern safety sciences and systems theory and design. Indeed, the book emphasizes how the growing awareness of systems-design thinking and the self-education and commitment to improving patient safety, by not only Dr. Leape but a wide range of other clinicians and health executives from both the private and public sectors, all converged to drive forward the patient safety movement in the US. Making Healthcare Safe is divided into four parts: I. In the Beginning describes the research and theory that defined patient safety and the early initiatives to enhance it. II. Institutional Responses tells the stories of the efforts of the major organizations that began to apply the new concepts and make patient safety a reality. Most of these stories have not been previously told, so this account becomes their histories as well. III. Getting to Work provides in-depth analyses of four key issues that cut across disciplinary lines impacting patient safety which required special attention. IV. Creating a Culture of Safety looks to the future, marshalling the best thinking about what it will take to achieve the safe care we all deserve. Captivatingly written with an “insider’s” tone and a major contribution to the clinical literature, this title will be of immense value to health care professionals, to students in a range of academic disciplines, to medical trainees, to health administrators, to policymakers and even to lay readers with an interest in patient safety and in the critical quest to create safe care.
Author : Peter Spurgeon,Mark-Alexander Sujan,Stephen Cross,Hugh Flanagan
Publisher : Springer Nature
Page : 183 pages
File Size : 46,8 Mb
Release : 2019-08-21
Category : Technology & Engineering
ISBN : 9783030182441
This book offers a new, practical approach to healthcare reform. Departing from the priorities applied in traditional approaches, it instead assesses – both theoretically and practically – the successful lessons learned in other safety-critical industries, and applies them to healthcare settings. The authors focus on the importance of human factors and performance measures to establish proactive, systematic methods for healthcare system design. This approach helps to identify potential hazards before accidents occur, enhancing patient safety. In addition, the book details the new approach on the basis of real-world applications in the NHS and insights from NHS staff. Case studies and results are presented, demonstrating the significant improvements that can be achieved in risk reduction and safety culture. Lastly, the book outlines what steps healthcare organisations need to take in order to successfully adopt this new approach. The approach and experiential learning is brought together through the development of a new holistic patient safety education syllabus.
Author : Kerm Henriksen
Publisher : Unknown
Page : 526 pages
File Size : 40,9 Mb
Release : 2005
Category : Medical
ISBN : CHI:70548902
v. 1. Research findings -- v. 2. Concepts and methodology -- v. 3. Implementation issues -- v. 4. Programs, tools and products.
Author : Anonim
Publisher : Department of Health and Human Services
Page : 744 pages
File Size : 40,8 Mb
Release : 2001
Category : Medical
ISBN : UOM:39015055825304
"This project aimed to collect and critically review the existing evidence on practices relevant to improving patient safety"--P. v.
Author : Charles Vincent,René Amalberti
Publisher : Springer
Page : 157 pages
File Size : 43,6 Mb
Release : 2016-01-13
Category : Medical
ISBN : 9783319255590
The authors of this book set out a system of safety strategies and interventions for managing patient safety on a day-to-day basis and improving safety over the long term. These strategies are applicable at all levels of the healthcare system from the frontline to the regulation and governance of the system. There have been many advances in patient safety, but we now need a new and broader vision that encompasses care throughout the patient’s journey. The authors argue that we need to see safety through the patient’s eyes, to consider how safety is managed in different contexts and to develop a wider strategic and practical vision in which patient safety is recast as the management of risk over time. Most safety improvement strategies aim to improve reliability and move closer toward optimal care. However, healthcare will always be under pressure and we also require ways of managing safety when conditions are difficult. We need to make more use of strategies concerned with detecting, controlling, managing and responding to risk. Strategies for managing safety in highly standardised and controlled environments are necessarily different from those in which clinicians constantly have to adapt and respond to changing circumstances. This work is supported by the Health Foundation. The Health Foundation is an independent charity committed to bringing about better health and health care for people in the UK. The charity’s aim is a healthier population in the UK, supported by high quality health care that can be equitably accessed. The Foundation carries out policy analysis and makes grants to front-line teams to try ideas in practice and supports research into what works to make people’s lives healthier and improve the health care system, with a particular emphasis on how to make successful change happen. A key part of the work is to make links between the knowledge of those working to deliver health and health care with research evidence and analysis. The aspiration is to create a virtuous circle, using what works on the ground to inform effective policymaking and vice versa. Good health and health care are vital for a flourishing society. Through sharing what is known, collaboration and building people’s skills and knowledge, the Foundation aims to make a difference and contribute to a healthier population.
Author : Charles Vincent
Publisher : John Wiley & Sons
Page : 430 pages
File Size : 49,9 Mb
Release : 2011-07-20
Category : Medical
ISBN : 9781444348071
When you are ready to implement measures to improve patient safety, this is the book to consult. Charles Vincent, one of the world's pioneers in patient safety, discusses each and every aspect clearly and compellingly. He reviews the evidence of risks and harms to patients, and he provides practical guidance on implementing safer practices in health care. The second edition puts greater emphasis on this practical side. Examples of team based initiatives show how patient safety can be improved by changing practices, both cultural and technological, throughout whole organisations. Not only does this benefit patients; it also impacts positively on health care delivery, with consequent savings in the economy. Patient Safety has been praised as a gateway to understanding the subject. This second edition is more than that – it is a revelation of the pervading influence of health care errors, and a guide to how these can be overcome. "... The beauty of this book is that it describes the complexity of patient safety in a simple coherent way and captures the breadth of issues that encompass this fascinating field. The author provides numerous ways in which the reader can take this subject further with links to the international world of patient safety and evidence based research... One of the most difficult aspects of patient safety is that of implementation of safer practices and sustained change. Charles Vincent, through this book, provides all who read it clear examples to help with these challenges" From a review in Hospital Medicine by Dr Suzette Woodward, Director of Patient Safety. Access 'Essentials of Patient Safety – Free Online Introduction': www.wiley.com/go/vincent/patientsafety/essentials